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Elea <br />In the pursuit of health <br />BlueMedicare Group PPO* Plan 1 <br />Outpatient Surgery <br />In -Network <br />• $150 Copayment for each outpatient <br />hospital facility visit <br />i <br />• $100 Copayment for each visit to an <br />ambulatory surgical center <br />Out -of -Network DED & 20% Coinsurance <br />In -Network / Out -of -Network <br />• $0 Copayment for physician services <br />Diagnostic Tests, X -Rays <br />Office <br />In -Network <br />• PCP $10 Copayment <br />• Specialist $30 Copayment <br />Out -of -Network DED & 20% Coinsurance <br />IDTF <br />In -Network $50 Copayment <br />Out -of -Network DED & 20% Coinsurance <br />Lab Services <br />Independent Clinical LabIn-Network <br />$0 Copayment <br />Outpatient Hospital <br />In -Network $15 Copayment <br />All Locations <br />Out -of -Network DED & 20% Coinsurance <br />Advanced Imaging (MRI, MRA, CT Scan, <br />PET Scan and Nuclear Medicine): <br />Office <br />In -Network $125 Copayment <br />Out -of -Network DED & 20% Coinsurance <br />IDTF <br />In -Network $125 Copayment <br />Out -of -Network DED & 20% Coinsurance <br />Outpatient Hospital <br />In -Network $150 Copayment <br />Out -of -Network DED & 20% Coinsurance <br />Y0011_31874 0414R4 EGWP C 06/2014 <br />2 <br />